Palatka Center For Rehabilitation And Healing
Inspection history, citations, penalties and survey trends for this long-term care facility in Palatka, Florida.
- Location
- 110 Kay Larkin Dr, Palatka, Florida 32177
- CMS Provider Number
- 105652
- Inspections on file
- 25
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Palatka Center For Rehabilitation And Healing during CMS and state inspections, most recent first.
A resident with a PICC line in the upper arm was observed with a transparent dressing that had not been changed according to the expected weekly schedule. An LPN stated that PICC dressings are supposed to be changed weekly, while another LPN indicated that the RN supervisor usually performs all PICC dressing changes but was not present. The DON confirmed that weekly PICC dressing changes are required and are the responsibility of the nurse on the cart, and acknowledged that this resident’s dressing should have been changed. There was no physician order for PICC dressing changes, despite a facility policy stating that wound care is to follow current standards of practice with physician orders documented on the Treatment Administration Record.
A resident had a physician order for daily abdominal staple wound care with normal saline and a dry dressing on the day shift, but the Treatment Administration Record lacked documentation that the ordered wound care was completed on several days. One LPN reported that dressings were changed when the resident was cared for but admitted forgetting to document on specific days, and another LPN could not recall whether the dressing was changed on one of the missing dates. This resulted in an incomplete medical record that did not accurately reflect the resident’s wound care as required by facility policy.
A resident receiving IV antibiotic therapy for a wound infection did not receive care under required enhanced barrier precautions. During a PICC line dressing change, an LPN did not wear a gown, despite the resident’s care plan directing use of enhanced barrier precautions per facility policy. The DON stated the resident should have been on enhanced barrier precautions due to the IV and wound, and that a gown should have been worn. Facility policy requires gown and glove use for high-contact care activities, including central line and wound care.
The facility failed to provide a rationale for not following pharmacy recommendations for three residents, involving medications like Oxybutynin, Gabapentin, and Rivaroxaban. Despite the pharmacist's advice to adjust or discontinue these medications due to risks like falls, the physician disagreed without justification, contrary to facility policy.
A resident with hemiplegia and other medical conditions was observed with a splint on one hand and a non-skid sock on the other, without proper authorization or documentation. Staff interviews indicated the sock's use was approved by the resident's daughter, but the facility's administrator stated it should not have been used. The facility's policy prohibits physical restraints without consent, highlighting a deficiency in policy adherence.
The facility failed to ensure accurate MDS assessments for two residents. One resident, with acute respiratory failure, was incorrectly documented as not receiving prescribed oxygen therapy. Another resident was inaccurately recorded as receiving insulin injections, despite no physician order, administration record, or diabetes diagnosis.
The facility failed to create comprehensive care plans for two residents, one with depression and behavioral issues and another with a UTI. The interdisciplinary team did not address the specific needs related to these conditions, as confirmed by the DON and Administrator.
The facility failed to administer blood pressure medication according to prescribed parameters for two residents, leading to administration errors. Additionally, a resident was left unsupervised with medication, contrary to professional standards. The DON confirmed the need for adherence to medication parameters and supervision during administration.
Two residents in the facility did not receive oxygen therapy as prescribed. One resident was observed with incorrect oxygen flow rates and without oxygen during certain activities, despite having a continuous oxygen order. Another resident received oxygen at a higher rate than prescribed. Staff interviews confirmed the discrepancies, and the facility's policy on oxygen administration was not adhered to.
A resident with chronic kidney disease was unnecessarily prescribed Sulfamethoxazole-Trimethoprim for prophylaxis without conducting a urinalysis or culture and sensitivity test to confirm a UTI. Facility staff, including the DON, APRN, and Medical Director, acknowledged the failure to follow the antibiotic stewardship policy, which requires appropriate testing before prescribing antibiotics.
Unsecured medications were found in the rooms of three residents, none of whom had self-administration orders or care plan documentation for medication self-administration. The DON confirmed that self-administration assessments were not completed, and the facility's policy requires medications to be stored in locked compartments accessible only to authorized personnel.
The facility failed to maintain proper infection control practices, as staff did not perform hand hygiene during medication administration for two residents. Additionally, respiratory equipment for two residents was not stored in bags when not in use, contrary to facility policy. Staff acknowledged these lapses, which were observed during a survey.
A resident with chronic kidney disease was prescribed antibiotics for a UTI without a urinalysis being conducted, contrary to the facility's antibiotic stewardship policy. Staff interviews revealed that antibiotics were administered without confirming a UTI through lab tests, and the facility's policy requiring diagnostic evidence before prescribing antibiotics was not followed.
The facility failed to maintain fire/smoke doors, which were found with chips, holes, and missing corners, compromising their fire protection rating. The damage was attributed to lifts and carts, as confirmed by the maintenance team. This deficiency was discussed with the facility's administration during the exit conference.
The facility failed to properly store portable oxygen cylinders, as they were found unlabeled in the soiled utility room, leading to potential confusion and delays in accessing full cylinders. Staff were unaware of this issue, indicating a lapse in oversight.
Two residents received incontinence care without proper infection control practices. A CNA did not perform hand hygiene or change gloves after applying barrier cream to a resident with multiple diagnoses, including a fracture and COPD. Another CNA failed to change gloves after peri-care before handling clean linens for a resident with conditions like acute embolism and diabetes. Both CNAs acknowledged the lapses, which violated the facility's hand hygiene and perineal care policies.
The facility failed to maintain a clean and homelike environment in one wing, with items such as blankets, cups, and gloves found on the floors of residents' rooms and bathrooms. Housekeeping services were limited to daytime hours, leaving CNAs responsible for cleaning during other shifts. The Director of Nursing confirmed these findings.
A resident with multiple health issues, including a MRSA infection and risk of falls, did not have a comprehensive care plan implemented. Observations showed missing fall mats, and the care plan lacked focus on contact isolation precautions, contrary to physician orders. This indicates a failure in meeting the resident's needs as per facility policy.
A facility failed to ensure staff used appropriate PPE for a resident on contact precautions due to MRSA. An LPN was observed in the resident's room without gloves or a gown while preparing food, contrary to the facility's policy and room signage. The resident had multiple diagnoses, including MRSA, and was under contact isolation. The DON confirmed the requirement for PPE, but the LPN did not comply.
Failure to Perform Timely PICC Line Dressing Changes per Standards of Practice
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate administration of IV therapy by not performing Peripherally Inserted Central Catheter (PICC) dressing changes according to professional standards for one resident. During observation, the resident was noted to have a PICC line in the right upper arm with a transparent dressing dated 2/11, indicating it had not been changed weekly as required. An LPN stated that PICC dressings are supposed to be changed weekly, believed to be on Saturdays, and another LPN reported that the RN supervisor typically changes all PICC dressings but was not present that day. The Director of Nursing confirmed that PICC dressings should be changed every week and that it is the responsibility of the nurse on the cart, acknowledging that this resident’s dressing should have been changed and that there was no physician order for PICC dressing changes. Review of the facility’s skin and wound management policy showed that wound care is to be managed based on current standards of practice, with a physician order documented on the Treatment Administration Record when skin impairment is identified, but no such order existed for this resident’s PICC dressing care. These findings demonstrate that the facility did not follow its own policy and professional standards regarding PICC line dressing changes and lacked appropriate physician orders for this aspect of the resident’s IV therapy care.
Failure to Accurately Document Ordered Wound Care Treatments
Penalty
Summary
The facility failed to ensure complete and accurate documentation of wound care treatments in the medical record for one resident. Resident #1 had a physician’s order dated 01/17/2026 for daily abdominal staple wound care with normal saline, pat dry, and application of a dry dressing on the day shift through 01/26/2026. Review of the Treatment Administration Record showed no documentation that the ordered abdominal wound care was completed on 01/18/2026, 01/19/2026, or 01/23/2026. In interview, one LPN stated she changed the resident’s abdominal dressing whenever she cared for the resident but acknowledged she must have forgotten to document the dressing changes on 01/18 and 01/23, while another LPN could not recall whether the dressing was changed on 01/19. The facility’s documentation policy requires clinical staff to document care and services in a manner that accurately reflects the clinical care provided and provides a complete account of the resident’s care, treatment, and response.
Failure to Use Enhanced Barrier Precautions During PICC Line Dressing Change
Penalty
Summary
The facility failed to implement its infection prevention and control program by not using enhanced barrier precautions during intravenous therapy care for Resident #2. On 02/27/2026 at 10:32 AM, an LPN was observed changing Resident #2’s PICC line dressing without wearing a gown. Resident #2 had an IV for antibiotic medications related to a wound infection, and the resident’s care plan dated 02/02/2026 specified that enhanced barrier precautions were to be provided per facility policy. The Director of Nursing stated that Resident #2 should be on enhanced barrier precautions due to the IV and wound, and that the LPN should have worn a gown, while also noting that there was no order for enhanced barrier precautions. The LPN reported not thinking a gown was needed to change a PICC line dressing. Review of the facility’s Enhanced Barrier Precautions policy showed that gown and glove use is required for high-contact resident care activities, including device care such as central lines and wound care for any skin opening requiring a dressing.
Failure to Provide Rationale for Disagreement with Pharmacy Recommendations
Penalty
Summary
The facility failed to provide a rationale when actions were not taken for pharmacy recommendations for three residents reviewed for unnecessary medication. For Resident #7, the consultant pharmacist recommended tapering or discontinuing Oxybutynin and Hydrocodone/APAP due to increased fall risk, but the physician disagreed without providing a rationale. The facility's policy requires that each resident's drug regimen be managed to promote their highest practicable wellbeing, yet the physician's responses lacked the necessary justification. Resident #84 was receiving Gabapentin and Guaifenesin without a stop date, both of which were flagged by the pharmacist for potential risks and lack of necessity. The physician disagreed with the pharmacist's recommendations to taper or add a stop date without providing a rationale. The Director of Nursing confirmed that the provider should document a reason for disagreement, but this was not done, indicating a failure to adhere to the facility's policy on drug regimen management. For Resident #99, multiple pharmacist recommendations were made regarding the timing and dosage of medications such as Rivaroxaban, Methotrexate, and Lorazepam, as well as the use of Duloxetine with a low creatinine clearance level. In each case, the physician disagreed with the recommendations without providing a rationale. Interviews with the Director of Nursing revealed that while the recommendations were reviewed, the required rationale for disagreement was not documented, which is contrary to the facility's policy aimed at ensuring residents' wellbeing.
Improper Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as evidenced by the use of a non-skid sock on the resident's hand without proper authorization or documentation. The resident, who was admitted with medical diagnoses including hemiplegia, hemiparesis, cognitive communication deficit, and contracture of the left hand, was observed on multiple occasions with a splint on her left hand and a non-skid sock on her right hand. These observations were made over several days, and there were no physician orders or consent forms authorizing the use of such devices as restraints. Interviews with staff revealed that the use of the sock was either requested or approved by the resident's daughter, but the facility's administrator confirmed that the resident should not have had a sock on her hand. The facility's policy on physical restraints clearly states that no physical restraint should be imposed on any resident for discipline or convenience, and defines physical restraints as any device that restricts freedom of movement or normal access to one's body. The lack of proper documentation and consent for the use of the sock as a restraint indicates a deficiency in the facility's adherence to its own policies and procedures regarding the use of physical restraints.
Inaccurate MDS Assessments for Oxygen Therapy and Insulin
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents. Resident #4, who was admitted with acute respiratory failure with hypoxia, heart failure, type 2 diabetes, and acute posthemorrhagic anemia, had a physician's order for continuous oxygen therapy at 3 liters per minute via nasal cannula. However, the MDS assessment dated 12/24/2024 incorrectly indicated that the resident was not receiving oxygen therapy. Additionally, Resident #143's MDS assessment dated 11/25/2024 inaccurately documented that the resident received insulin injections over the last seven days, despite the absence of a physician's order for insulin, no insulin administration recorded in the Medication Administration Record for November 2024, and no diagnosis of Diabetes Mellitus.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their specific medical needs. Resident #21, who has a history of depression, dementia, and insomnia, did not have a care plan that addressed potential behaviors related to these diagnoses. Despite documented instances of the resident refusing care, such as showers and lab tests, and being on psychiatric medications, the interdisciplinary team did not create a care plan focusing on these behaviors or the resident's use of antidepressants. The Director of Nursing acknowledged that a care plan should have been initiated to address these issues. Similarly, Resident #44, who was diagnosed with a urinary tract infection (UTI), did not have a care plan that included the UTI diagnosis or the prescribed antibiotic therapy. The resident was ordered Macrobid for the UTI, but the interdisciplinary team failed to document a care plan for this condition or the associated treatment. The facility's Administrator confirmed that the team was responsible for identifying and care planning for the UTI and antibiotic therapy, which was not done.
Medication Administration Errors and Lack of Supervision
Penalty
Summary
The facility failed to administer blood pressure medication according to the prescribed parameters for two residents. Resident #103 was given Metoprolol Tartrate despite having systolic blood pressure readings below the prescribed threshold of 120 on multiple occasions in January and February 2025. The Director of Nursing acknowledged that the medication was administered outside of the parameters and emphasized the need for staff to follow the provider's orders and seek clarification if needed. The Medical Director confirmed that there were no adverse medical issues resulting from this administration error. Resident #143 received Midodrine despite having systolic blood pressure readings above the prescribed threshold of 110. The medication was administered on several occasions in January and February 2025 when the blood pressure readings were higher than the specified limit. The Director of Nursing stated that nurses are expected to administer medication according to the parameters and seek clarification from the physician if needed. It was noted that the medication order for Resident #143 was a transcription error, which should have indicated holding the medication for systolic blood pressure greater than 130. Additionally, the facility failed to follow professional standards of practice during medication administration for Resident #456. The resident was found holding a medication cup with tablets and a capsule without a nurse present in the room. The nurse was attending to a computer screen outside the room, contrary to the expectation that nurses should observe residents taking their medications. The Director of Nursing confirmed that the nurse should have stayed in the room until the resident had taken the administered medications.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility staff failed to administer oxygen therapy according to professional standards for two residents. Resident #8 was observed on multiple occasions with incorrect oxygen flow rates. On one occasion, the resident was seen at the nurse's station without any oxygen therapy, despite having a physician's order for continuous oxygen at 2 liters per minute (LPM) via nasal cannula for shortness of breath. Interviews with staff revealed a lack of adherence to the prescribed oxygen flow rate, with the Director of Nursing stating that residents should be kept on the prescribed flow at all times, and the Activities Assistant confirming that the resident was not on oxygen during certain activities. Similarly, Resident #125 was observed receiving oxygen at 3 LPM, contrary to the physician's order of 2 LPM via nasal cannula. The resident mentioned that the nurse had changed the flow rate and tubing, but they did not adjust the machine themselves. A registered nurse confirmed the incorrect flow rate and adjusted it after checking the resident's orders. The Director of Nursing emphasized the importance of monitoring and maintaining the correct flow rate. The facility's policy on oxygen administration specifies that oxygen should be started at the prescribed rate, which was not followed in these cases.
Failure to Adhere to Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary antibiotic use, specifically concerning the administration of Sulfamethoxazole-Trimethoprim (Bactrim DS) for prophylaxis. The resident, who had a diagnosis of chronic kidney disease stage 4, was prescribed Bactrim DS for seven days following a report of painful urination. However, there was no urinalysis (UA) or culture and sensitivity (C&S) test conducted to confirm the presence of a urinary tract infection (UTI) before the antibiotics were administered. The facility's policy on antibiotic stewardship, which requires a complete assessment and appropriate testing before prescribing antibiotics, was not followed in this case. Interviews with the facility's staff, including the Director of Nursing, Advanced Practice Registered Nurse, Infection Preventionist, and Medical Director, revealed a lack of adherence to the facility's antibiotic stewardship policy. The staff acknowledged that antibiotics were started without obtaining a UA, and the Medical Director admitted to ordering the antibiotics without ordering labs. The Infection Preventionist noted that the facility's policy was not followed, and the antibiotics should have been discontinued if the UA was negative. This oversight in following the established protocol for antibiotic use led to the unnecessary administration of antibiotics to the resident.
Unsecured Medications Found in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with professional standards, as unsecured medications were observed in resident rooms. During observations, a bottle of Fluticasone Propionate Lotion was found on a bedside table of a resident who did not have a self-administration order or care plan focus for medication self-administration. Similarly, a circular white tablet was found in a medication cup on another resident's bedside table, and four circular white tablets were found on a third resident's bedside table. None of these residents had physician orders or care plans documenting a focus for medication self-administration. The Director of Nursing acknowledged that self-administration assessments were not completed for the residents involved and stated that nursing staff should remain with residents to ensure medication is taken and not left unattended. The facility's policy requires that all medications, except for Emergency Drug Kits, be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel. This policy was not adhered to, leading to the observed deficiencies.
Infection Control and Equipment Storage Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with hand hygiene protocols during medication administration. Specifically, a Registered Nurse (RN) was observed administering intravenous medication to a resident without performing hand hygiene before donning gloves or after removing them. Similarly, a Licensed Practical Nurse (LPN) was seen preparing and administering oral medications to another resident without using hand hygiene. Both staff members acknowledged their failure to adhere to the facility's hand hygiene policy, which emphasizes hand hygiene as the primary means to prevent infection spread. Additionally, the facility did not adhere to acceptable standards for storing respiratory care equipment. Observations revealed that nebulizer masks and nasal cannulas were not stored in bags when not in use, contrary to the facility's policy. This was noted in the cases of two residents, where respiratory equipment was left exposed on bedside tables or floors. Interviews with nursing staff and the Director of Nursing confirmed that such equipment should be bagged when not in use to prevent nosocomial infections, as outlined in the facility's respiratory therapy equipment policy.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its antibiotic stewardship protocol by not adequately monitoring the use of antibiotics for a resident with a urinary tract infection (UTI). The resident, who had a diagnosis of chronic kidney disease stage 4, was prescribed Bactrim DS for prophylaxis without a urinalysis (UA) being conducted to confirm the presence of a UTI. The medication administration record showed that the resident received 13 doses of the antibiotic over a period of seven days. Interviews with facility staff revealed a lack of adherence to the facility's antibiotic stewardship policy. The Director of Nursing acknowledged that a UA should have been collected, and the Advanced Practice Registered Nurse admitted to an oversight in not ordering the UA. The Infection Preventionist and Medical Director both indicated that antibiotics were started without confirming a UTI through laboratory tests, which is contrary to the facility's policy that emphasizes the need for a UA and culture and sensitivity (C&S) before starting antibiotics. The facility's policy on antibiotic stewardship and clinical protocol for UTIs were not followed, as antibiotics were prescribed and administered without complete diagnostic evidence. The policy requires that antibiotics be prescribed with a clear indication of use, including a start and stop date, and that treatment decisions be based on clinical signs and symptoms. The failure to conduct a UA and C&S before administering antibiotics led to a breach in the facility's protocol, as confirmed by staff interviews and record reviews.
Facility Fails to Maintain Fire/Smoke Doors
Penalty
Summary
The facility failed to maintain the integrity of fire/smoke doors, which are crucial for resisting the passage of smoke and providing fire protection. During a facility tour, it was observed that the fire/smoke doors had chips and holes, with some doors missing entire corners, allowing visibility into the next room. This condition compromises the fire protection rating of the doors, as the exposed door cores provide less fire resistance than required. The issue was confirmed during an interview with the Regional Maintenance Director, Maintenance Director, and Assistant Maintenance Director, who acknowledged that the damage was caused by lifts and carts frequently tearing up the doors. These findings were discussed with the facility's administration and maintenance team during the exit conference, highlighting the facility's failure to maintain the required standards for fire/smoke doors as per NFPA 101 and NFPA 80 regulations.
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to maintain proper storage of portable oxygen cylinders, specifically E Cylinders, as observed during a facility tour. The cylinders were found in various areas of the soiled utility room without appropriate labeling to distinguish between full and empty cylinders. This lack of labeling could lead to confusion and delays in accessing a full cylinder when needed urgently. During interviews with the Regional Maintenance Director, Maintenance Director, and Assistant Maintenance Director, it was revealed that they were unaware of the improper storage practices. The findings were confirmed by these staff members, indicating a lapse in oversight and adherence to the NFPA 99 (2012 Edition) standards, specifically CH 11.6.5.3, which requires empty cylinders to be marked to avoid confusion.
Infection Control Lapses During Incontinence Care
Penalty
Summary
The facility failed to adhere to infection control practice standards during incontinence care for two residents. Resident #5, who has multiple diagnoses including a displaced intertrochanteric fracture and chronic obstructive pulmonary disease, was observed receiving incontinence care from a CNA who did not perform hand hygiene before donning gloves. The CNA removed the soiled brief, applied barrier cream, and placed a clean brief and under pad on the resident without changing the soiled gloves. The CNA acknowledged the mistake during an interview, stating that handwashing and glove changing should have occurred after applying the barrier cream. Similarly, Resident #6, with diagnoses such as acute embolism and type 2 diabetes mellitus, was also subject to improper infection control practices. During incontinence care, another CNA failed to change gloves after performing peri-care and before handling clean linens. The CNA admitted to not following proper infection control procedures, which included changing gloves and washing hands after completing peri-care. The facility's policies on perineal care and hand hygiene emphasize the importance of handwashing and glove changing to prevent infections, which were not adhered to in these instances.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of its wings, as observed during a facility tour. Specific deficiencies included a blanket on the floor near the window and a plastic cup under the bedside table in a resident's room, a medication cup on the floor in another resident's room, and a plastic cup and blue glove on the bathroom floor shared by two residents. Additionally, there was a dried brown substance on the toilet and a towel on the floor under the sink in another resident's room. Interviews with staff revealed that housekeeping services were only available during the day shift, leaving CNAs responsible for cleaning during other shifts. The Director of Nursing confirmed these findings.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for a resident, leading to deficiencies in care. The resident, who was admitted with multiple diagnoses including a dislocated hip, chronic ulcers, and a MRSA infection, was identified as being at risk for falls. Despite this, observations revealed that fall mats, which were part of the resident's care plan interventions, were not present by the resident's bed. This was confirmed by a Licensed Practical Nurse during an observation and interview, indicating a failure to implement the care plan interventions. Additionally, the resident was under contact isolation precautions due to a MRSA infection, as per a physician's order. However, the care plan did not include a focus on contact isolation precautions, which was verified by the Director of Nursing. The facility's policy on person-centered care planning requires that care plans be individualized and comprehensive, addressing the resident's medical, nursing, and psychosocial needs. The absence of these critical elements in the care plan highlights a deficiency in meeting the resident's needs.
Failure to Use PPE for Resident on Contact Precautions
Penalty
Summary
The facility failed to ensure that staff used appropriate personal protective equipment (PPE) while providing direct care to residents on contact precautions, specifically for a resident with a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection. During an observation, a Licensed Practical Nurse (LPN) was seen in the resident's room without wearing gloves or a gown while preparing food, despite clear signage indicating the need for such precautions. The signage instructed everyone to clean their hands before entering and upon leaving the room, and for providers and staff to wear gloves and a gown before room entry and discard them before room exit. The resident involved had multiple diagnoses, including a MRSA infection, and was under contact isolation precautions as per a physician's order. The facility's policy on transmission-based precautions, revised in September 2022, required staff and visitors to wear gloves and a disposable gown upon entering the room. The Director of Nursing confirmed that staff are supposed to follow these precautions when residents are on specific isolation. However, the LPN admitted to not wearing the required PPE, stating it was only necessary when providing direct care, despite the resident's MRSA status.
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Surveyors found that the facility failed to comply with 42 CFR 483.73(a) by not conducting the required annual review and update of its Emergency Preparedness (EP) plan. During record review, no documentation showed that the EP plan had been reviewed or updated within the past year, and the Administrator confirmed that the Emergency Management Plan had not been reviewed or revised as required.
Surveyors found that smoke/fire-rated enclosures were not properly maintained, with penetrations in smoke barriers in several general storage rooms across multiple smoke compartments. The Maintenance Director stated that insulation and fiberglass were used to pack and cover these holes but could not confirm that the materials were approved for fire-rated construction. Inspectors observed penetrations covered with fiberglass and noted a hole in one fiberglass panel in a storage room, resulting in a deficiency under NFPA 101 requirements for smoke barrier construction.
Surveyors found that fixed patient-care electrical equipment was not properly maintained or inspected in accordance with NFPA 99. In one room, a bedside remote had mismatched insulation and exposed wiring, and in another room, a call button receptacle had exposed low-voltage conductors. The Maintenance Director acknowledged both issues and reported that new bed remotes had been received but not yet installed.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with strong, persistent urine and feces odors noted throughout multiple halls and confirmed by staff. On two nursing units, hallways and resident rooms contained torn flooring, food debris, broken blinds, dirty and leaking toilets and sinks, rusted and corroded fixtures, missing outlet covers with oxygen concentrators plugged in, exposed light sockets, unmade and visibly soiled beds, and black, mold-like substances on walls and around toilet bases. Bathrooms had missing ceiling tiles, cracked door facings with brown stains, used briefs and torn toilet paper on floors, and toilets with brown or rust-like buildup. Outside, the patio and fencing area had broken and rotted railings, exposed rusted nails, fallen palm fronds, and overgrown vegetation, and the Administrator acknowledged the area was not safe for residents. Housekeeping and maintenance staff described daily cleaning and a work-order process, but the Maintenance Director reported being unaware of many of the observed issues, and the DON confirmed there was no specific environmental cleaning policy despite job descriptions and a general policy requiring a safe, sanitary, and comfortable environment.
A resident exited the building through a bedroom window, walked off the property, and was observed and redirected by staff with assistance from law enforcement, who encountered the resident down the road and helped escort the resident back. The facility’s internal documentation lacked staff or witness statements and characterized the event as the resident remaining on facility grounds without injury. Despite the resident’s account, a police report, and a maintenance staff report confirming that the resident left the premises and that law enforcement responded, the DON did not report the incident to required state and federal agencies, even though the DON acknowledged that any incident involving law enforcement response must be reported.
A resident with moderate cognitive impairment and a history of stroke was repeatedly observed over several days in visibly soiled clothing and bedding, with a strong urine odor, despite stating multiple times that he had requested assistance with changing and hygiene. Documentation indicated he was independent with toileting and personal hygiene and only occasionally incontinent, but his care plan lacked detail on the level of assistance needed, while an LPN reported he actually required staff help with bathing, grooming, toileting, and care. Laundry practices involved leaving clean, labeled clothing bagged in the linen room for nursing staff to distribute rather than returning it directly to rooms, and the DON reported that staff were expected to round every two hours and as needed to keep residents clean and dry, although there were no written ADL or resident care policies in place.
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with multiple cardiopulmonary conditions and a documented full code status was found unresponsive without pulse or respirations during the night shift. A CNA notified the RN, who either instructed CNAs to clean and cover the resident or, per her and an LPN’s account, called a code blue and performed CPR with the LPN for about 20 minutes before stopping, without calling 911. The RN believed the resident was on hospice and did not verify code status, then notified the DON, provider, and family instead of EMS. Several hours later, after the DON called the facility and asked whether 911 had been contacted, the RN called 911 and briefly reinitiated CPR shortly before EMS arrived and pronounced the resident deceased, documenting postmortem changes. The facility’s investigation and root cause analysis found that staff failed to follow policy requiring immediate EMS activation and continuous CPR for full code residents until EMS arrival, leading to an Immediate Jeopardy finding.
A resident with full code status was found unresponsive without respirations or pulse during the night shift. An RN and an LPN initiated CPR but did not activate EMS, and they discontinued CPR after about 20 minutes. The RN, who lacked documented orientation and competency assessment and had obtained BLS certification through a fully online, non–instructor-led course, pronounced the resident deceased without authority and later stated she believed the resident was on hospice and did not verify code status. The LPN’s BLS certification was expired, and a CNA with an expired BLS certification performed several chest compressions despite facility policy that CNAs were not to perform CPR. The RN had not participated in documented code blue drills, and leadership confirmed that required clinical orientation and skills competencies had not been completed for her, leading surveyors to determine that staff were not adequately trained or competent to respond to a cardiopulmonary arrest for a full code resident, resulting in an Immediate Jeopardy finding.
Surveyors found multiple instances of improper use of relocatable power taps (RPTs) and extension cords during a facility tour with the Maintenance Director. In the social services office, an RPT was plugged into another RPT connected to a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was plugged into an extension cord, and in the MDS office, an RPT was plugged into another RPT with an outlet adapter in use. These conditions did not comply with NFPA 101, NFPA 99, and NFPA 70 standards governing electrical equipment, power strips, and extension cords.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness (EP) Program under 42 CFR 483.73(a). During record review at 4:00 PM, surveyors examined the facility’s EP documentation and found no evidence that the emergency preparedness plan had been reviewed or updated on an annual basis as required. The regulation mandates that LTC facilities develop and maintain an emergency preparedness plan that is reviewed and updated at least annually to comply with applicable Federal, State, and local emergency preparedness requirements. In an interview, the Administrator acknowledged that the facility’s Emergency Management Plan had not been reviewed or updated. No documentation was provided to show that the required annual review and update of the EP plan had occurred. The deficiency is based solely on the lack of documented annual review and update of the emergency preparedness plan by facility administration; no specific resident cases or clinical events were described in the report.
Plan Of Correction
Preparation and/or execution of the Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law. Facility EP was reviewed and signed off on by the DON, Maintenance Director and Administrator. The facility has determined that all residents have the potential to be affected. An in-service education program will be conducted by the administrator. The administrator will conduct monthly random checks to verify completed documentation.
Improper Repair of Smoke Barrier Penetrations in Multiple Smoke Compartments
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to penetrations in smoke barriers in multiple smoke compartments. During an interview, the Maintenance Director reported that insulation was used to pack holes and then covered with fiberglass in general storage rooms in smoke compartments 1, 2, and 3, but was unable to confirm whether these materials were approved for use in fire-rated walls. Subsequent observation showed that the penetrations were indeed covered with fiberglass, and one general storage room in smoke compartment 2 had a hole in one of the fiberglass panels. The report states that this failure to properly maintain penetrations through smoke/fire-rated construction could allow smoke and flammable gases to spread to other areas and cause the smoke/fire-rated construction to fail to perform as designed.
Failure to Maintain and Inspect Patient-Care Electrical Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s compliance with NFPA 99 requirements for testing and maintaining fixed patient-care electrical equipment. During an observation in one resident room, the bedside remote was found to have two different types of insulation and exposed wiring. In another resident room, the call button receptacle was observed with exposed low-voltage conductors. These conditions were noted during a survey of two of six smoke compartments. During an interview conducted at the time of the observations, the Maintenance Director stated that the facility had just received a new shipment of bed remotes and had not yet replaced the existing ones. The Maintenance Director also acknowledged the issue with the exposed conductors at the call button receptacle. The surveyors cited this as a failure to properly inspect and maintain fixed patient care electrical equipment in accordance with NFPA 99 (2012 Edition), sections 10.3 and 10.5.2.1.
Widespread Odors and Environmental Disrepair in Resident Care Areas
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment as required by 42 CFR 483.10(i). Upon entrance to the building on multiple days, surveyors noted a strong, pungent odor of urine and feces throughout the facility, with the odor particularly strong on the 200, 300, and 400 halls. Staff interviews confirmed that the building "usually smells like" urine, and staff attributed the odor to residents defecating and urinating on the floor, an old building structure, and cleaning products that sanitize but do not deodorize. Housekeeping staff reported that they clean resident rooms daily but that nursing staff must first clean fecal and urine waste before housekeeping can sanitize, and delays by nursing staff in doing so postponed housekeeping’s ability to address the odors. On the 300 unit, surveyors observed multiple environmental and sanitation issues in resident rooms and bathrooms. The hallway had torn flooring, food particles, and a butter knife on the floor. Individual rooms had food debris, a straw on the floor, and broken blinds. Bathrooms contained dark brown stains on walls, rusted ceiling tile trim, toilets with brownish substances inside, and wet floors around toilets. Trim was missing around toilet bases, exposing a black, mold-like substance. Corroded and rusted sink faucet handles, leaking faucets, rusted pipes under sinks with buildup of corrosion, and rusted sprinklers were observed. Some toilets and three-in-one commodes had duct tape on them, and bathroom walls had black, mold-like substances. Doors and door facings showed rust, scrape marks, chipped and peeling paint, and exposed wood. In some rooms, electrical outlets had no covers while oxygen concentrators were plugged into them, boards covered windows, light fixtures over beds lacked covers with sockets exposed, and one fixture had only one bulb. A resident bed appeared dirty with a black substance on it, and dresser drawers were broken with drawer fronts on the floor. On the 400 unit, surveyors again noted a strong odor of urine upon entry and found additional environmental deficiencies. Bathrooms had missing ceiling tiles, broken emergency light covers with no pull strings, and toilet tank covers that did not fit properly, exposing the inside of the tank. In one bathroom, torn toilet paper and used briefs were lying in the corner of the floor, and toilets had brown, rust-like substances inside the bowls. Door facings appeared cracked with brown substances along the sides, and toilets had brownish-black buildup around the bases with broken, peeling trim. Light bases on walls had rust-like appearances, multiple rooms had broken or missing blinds, and some outlets lacked covers while oxygen concentrators were plugged into them. Some rooms had unmade beds, exposed wires at outlets, toilets with dark brown-black rings around the base and flooring, uncovered light fixtures, leaking sinks with rusted pipes, loose flooring, loose toilet seats, and dry red substances on door frames. Surveyors also observed deficiencies in the outdoor patio area adjacent to the locked unit. The gate code was broken, and a resident lock was placed on the gate. The patio and surrounding fencing had fallen palm fronds on the grass, broken and rotted wooden fence railings, unsteady railings, and multiple exposed rusted nails protruding from the railings where boards were broken or detached. Overgrown trees and bushes from the perimeter extended through the fence railings. When asked, the Administrator acknowledged that the area was not safe for residents and stated that they planned to have it redone in the future. The Maintenance Director reported that he and one other maintenance person relied on work orders and verbal reports to identify needed repairs and stated he was not aware of the specific room and equipment issues on the 300 and 400 units. Housekeeping staff stated they would report broken items via a work order book or text to maintenance, but one housekeeper, who cleaned the 400 unit daily, denied noticing stains or biohazard-like materials on walls and door frames despite the surveyors’ observations. Review of facility documents showed that the housekeeper job description required staff to maintain assigned work areas in a clean, safe, comfortable, and attractive manner and to report maintenance problems noted during cleaning. A facility policy titled "Policies and Practices - Control" stated that the facility must maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the public. The DON stated that blinds had been changed out and new cabinets and door handles purchased, and that staff were directed to use standard precautions when cleaning rooms, but also stated there was no policy specific to cleaning the environment. These observations and interviews demonstrated that the facility did not maintain sanitary, orderly, and comfortable interior conditions, did not adequately control offensive odors, and did not ensure that the physical environment, including resident rooms, bathrooms, and outdoor areas, was maintained in a safe, clean, and homelike condition as required by regulation.
Failure to Report Elopement Incident Involving Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to required state and federal agencies as mandated by 42 CFR 483.12(c). On the referenced date, Resident #5 exited the building through his bedroom window around 12:15 PM and walked across the facility property toward the perimeter fence. A CNA observed the resident outside and called for assistance, after which staff redirected and escorted the resident back into the building and placed him on one-to-one supervision. The facility’s internal incident documentation noted the window exit and subsequent maintenance inspection of the window seals but did not include any staff or witness statements. The DON later stated that the resident never left facility grounds and was returned without injury, and therefore the incident was not considered reportable. However, interviews and external records showed that the resident did leave the facility premises and that law enforcement was involved. Resident #5 recalled being outside the facility, being brought back by staff and a “police man,” and being told by the officer not to leave again. A police report from the local police department confirmed an encounter with the resident outside the facility and that an officer assisted staff in escorting him back. Maintenance staff (Staff G) also reported that the resident climbed out the window, left the facility property, and was stopped “down the road,” then redirected back with law enforcement assistance. In interviews, the DON initially denied that law enforcement had been notified or involved, then later acknowledged that law enforcement had responded but asserted they did not come into the facility. The DON also confirmed awareness that any incident in which law enforcement investigates or responds is required to be reported, yet the elopement and law enforcement involvement were not reported to the State Survey Agency or other required officials within the required time frames.
Failure to Provide Timely ADL and Hygiene Care to a Dependent Resident
Penalty
Summary
Surveyors found that the facility failed to provide necessary ADL care, including grooming and hygiene, to a dependent resident over multiple days. The resident was repeatedly observed in visibly soiled clothing with a strong odor of urine, first standing in his doorway holding onto a wheelchair with wet navy pants saturated down to his calves, stating he had been waiting for staff to change his clothes. More than an hour later the same day, he remained in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, he was again observed wearing the same soiled clothes, smelling of urine, with his shirt stained with food and a dark liquid. His room had a strong urine odor, his bed was soiled with urine, and only two pairs of pants were seen on a chair with no other clothing available in the room. On a subsequent observation, he was seated on the edge of his bed wearing different pants and no shirt, with yellow-stained sheets beneath him and his previously soiled clothes on the floor; he reported that he had requested assistance but no staff had come, so he changed himself. Record review showed the resident had a history of stroke and repeated unspecified conditions, with a recent Quarterly MDS indicating moderate cognitive impairment (BIMS score of 10). The MDS documented him as independent for toileting, showering, personal hygiene, and related ADLs, and only occasionally incontinent, but his care plan did not specify the level of assistance he required for incontinence care and other ADLs. In contrast, an LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and care, and that he did not refuse such assistance and appropriately requested help. The LPN also explained that personal clothing was laundered at the facility and left bagged in the linen room for nursing staff to distribute, rather than being returned directly to resident rooms. The DON stated that staff were expected to follow best practices, including rounding every two hours and as needed to keep residents clean and dry, and acknowledged that all residents required some level of assistance with ADLs. The DON further stated the facility had no written ADL, resident care, or quality of care policies, despite these expectations.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Failure to Provide Required CPR and Activate EMS for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate and appropriate basic life support, including CPR, to a resident with a documented full code status when the resident was found unresponsive. The resident had diagnoses including a slow-progressing circulatory condition involving narrowing or blockage of vessels, a condition that restricts airflow and makes breathing difficult, and other listed conditions. The physician’s order specified “Full Code,” and the care plan documented that the resident was under court-ordered guardianship with wishes honored as full code. The facility’s policy required that in the event of cardiac or respiratory arrest, staff immediately call for assistance, overhead page a code, begin CPR in the absence of a valid DNR, and continue CPR until EMS assumes responsibility or the resident responds. On the night of the incident at approximately 2:00–2:07 a.m., a CNA found the resident unresponsive in bed and notified the RN on duty. One CNA’s written statement indicated that the RN said she already knew the resident was going to die and instructed the CNA to clean and cover the resident. Another CNA’s account stated that the RN came to the room, took vital signs, and then instructed her to clean the resident. The RN’s own written statement and interview indicated that she called a code blue, that an LPN brought the crash cart, and that they performed CPR for approximately 20 minutes. The LPN’s statement corroborated that a code blue was called, that he brought the crash cart, and that CPR was performed for about 20 minutes before the RN stopped and stated that the resident was gone or words to that effect. The RN acknowledged that the resident had no vital signs but was warm and not responding, and she stated that she believed the resident was on hospice and therefore did not call 911. After CPR was discontinued, the RN did not activate EMS and instead notified the DON, the provider, and the resident’s family. The DON documented receiving a message from the RN that the resident had no pulse and no blood pressure and that the assigned nurse had initiated CPR but was unable to revive the resident. The DON later received a text from the RN that the resident had expired. The DON stated that at approximately 6:00 a.m. she called the facility and asked if 911 had been called, and upon learning it had not, she instructed the RN to call 911. The RN then reinitiated CPR at around 6:00 a.m., approximately four hours after the resident was first found without pulse or respirations, and stated that they tried to do something until EMS arrived because EMS had to see them doing CPR. EMS records showed activation at 6:18 a.m., arrival at 6:27 a.m., and pronouncement of death at 6:31 a.m., with documentation that CPR was not attempted by EMS because it was considered futile and that the resident exhibited postmortem changes. The Medical Director confirmed that the resident was full code and stated that staff should have started CPR and called 911 and that CPR should not be done four hours after a resident is pronounced dead. The facility’s investigation and a root cause analysis concluded that the RN and LPN did not follow the facility’s established policy and procedure to call 911 and administer CPR to a full code resident until EMS arrival. The root cause was identified as the nurse’s belief that the resident was on hospice and her failure to check the resident’s code status as outlined in facility policy. The surveyors determined that the failure to immediately activate EMS and to continue CPR until EMS arrival for this full code resident constituted noncompliance with the requirement to provide basic life support and resulted in an Immediate Jeopardy determination.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. Resident #1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All codes to 1.1.26 were reviewed to ensure protocol was followed. No outliers were noted. All licensed nurses received education from the Director of Nursing and/or nursing management on [R] policy and procedure and Florida [R] policy. This includes where to find the code status. Education addressed what to do for full code hospice residents. Education completed with CNA's that protocol is that they do not assist with [R] or breaths during a [R] event. All education will be added to new hire orientation. Code drills will occur 3 x weekly x 4 weeks, followed by 2 x weekly x 4 weeks, followed by 1 x weekly x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Educated licensed nurses on CPR policy and procedure and Florida Do Not Resuscitate (DNRO) policy, including where to find code status and what to do for full code hospice residents; emphasized initiating emergency services immediately when resident is full code, continuing CPR until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS.
- Implemented emergency response “Code Blue” drills on all three shifts, including full code and full code hospice scenarios, with emphasis on calling 911 immediately.
- Educated licensed nurses and CNAs on the facility abuse and neglect policy, including resident rights.
- Required licensed nurses to complete a CPR post-test; restricted staff who have not completed education/testing from working until completion.
- Educated licensed nurses regarding change in condition.
- Placed laminated instructions on how to overhead page during a code at all nursing station phones and other designated phones.
- Held a Quality Improvement Performance Committee meeting to review root cause analysis findings and approve recommendations.
- Held a Quality Improvement Performance Committee meeting to review progress of the plan and approve recommendations.
- Completed a “like resident” audit of all expired residents and rehospitalizations for a defined period to determine whether involved staff were the same as the code event and whether proper procedure was followed.
Failure to Provide Competent CPR Response and Verify Code Status for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff possessed and demonstrated the competencies required to respond appropriately to a cardiopulmonary emergency for a resident with full code status. Resident #1, who was designated as full code, was found unresponsive and without respirations or pulse at approximately 2:07 a.m. Clinical staff, consisting of an RN (Staff A) and an LPN (Staff B), initiated CPR but did not activate Emergency Medical Services (EMS) as required by facility policy for a full code resident. After approximately 20 minutes of CPR, the RN and LPN stopped resuscitation efforts without EMS involvement. The RN, without authority to do so, pronounced the resident deceased based on the absence of vital signs and did not verify the resident’s code status before discontinuing CPR. The RN later stated she believed the resident was on hospice and therefore did not call 911, and that she was confused about which residents were hospice and which were full code. The LPN reported that he assumed the RN had called 911 and continued CPR for about 20 minutes until the RN “called the code” and left, and he acknowledged that he knew CPR should continue until EMS arrival but did not speak up. Four hours after CPR was stopped, at approximately 6:00 a.m., the RN restarted CPR and activated EMS after receiving instructions from the DON. The investigation further identified that the RN had no documented orientation, onboarding education, or skills competency assessments since hire, despite being promoted to weekend supervisor. Her BLS certification had been obtained through a fully online course without an instructor or live feedback. The LPN’s BLS certification was expired, and a CNA who performed several chest compressions also had an expired BLS certification, even though facility policy did not permit CNAs to perform CPR. Facility records showed that monthly code blue drills had been conducted, but there was no documentation that the RN had ever participated in these drills. Leadership interviews confirmed that required clinical orientation and competency evaluations had not been completed for the RN, and that she had failed tests for a clinical manager position but was nonetheless functioning in a supervisory role. These actions and omissions led surveyors to determine that staff were not adequately trained or competent to respond to cardiopulmonary arrest for residents with full code status, resulting in an Immediate Jeopardy determination. The facility’s own root cause analysis, as reflected in meeting minutes, identified that the nurse did not check the resident’s code status and lacked knowledge about when CPR could be discontinued and when 911 should be called. The analysis documented that the nurse believed the resident was hospice and therefore did not start or continue CPR appropriately or call EMS when the resident was found without respirations and pulse. The facility assessment tool and policies referenced the need for staff training and competencies in identifying changes in condition, end-of-life care, advance care planning, and adherence to the CPR policy, but the documented events showed that these expectations were not met in practice for the staff involved in this incident. Surveyors concluded that the failure to ensure nursing staff were trained and competent to respond appropriately to cardiopulmonary arrest for a full code resident, including immediate initiation and continuation of CPR and activation of EMS, constituted noncompliance with requirements for sufficient and competent nursing staff. The failure affected Resident #1 and placed other full code residents at risk, leading to an Immediate Jeopardy finding that was later reduced in scope and severity after verification of an acceptable Immediate Jeopardy removal plan.
Plan Of Correction
This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors' findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied Resident # 1 no longer resides in the facility as of 4.7.26. This has the potential to affect all residents in the facility. All licensed nurses were audited to ensure current [R] certification. Facility will ensure [R] certification through a [R] provider whose training includes a [R] on session either in a physical or virtual instructor-led setting in accordance with accepted national standards. Human resources, or designee, will audit monthly to ensure all licensed nurses have a current [R] certification.Education was completed with licensed nurses on initiating [R] services immediately when a resident is full code. Education included that [R] is to continue on a full code resident until [R] arrives and that the nurse cannot pronounce [R] on the full code resident and/or stop [R] until instructed by [R].Education will be added to new hire orientation.7 random licensed nurses will complete a knowledge quiz related to code events. Per week x 4 weeks, followed by 5 nurses x 4 weeks, then 3 nurses x 4 weeks. Results will be brought to QAPI to determine need for ongoing auditing.
Removal Plan
- Regional Director of Clinical Services educated the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code; Administrator and DON signed the education
- Regional Director of Clinical Services provided documented education to the Administrator and Director of Nursing regarding the CPR policy and the need to immediately contact emergency medical services (911) in the event of a full code
- Director of Nursing and/or nursing management educated all licensed nurses on the CPR policy and procedure, including where to find code status and what to do for full code hospice residents
- Reinforced through education that CPR must be initiated immediately for full code residents, continued until EMS arrives, and that nurses cannot pronounce death or stop CPR on a full code resident unless instructed by EMS
- Conducted an Ad Hoc Quality Improvement Performance Committee meeting to review root cause analysis recommendations related to the incident; recommendations approved
- Conducted a follow-up Ad Hoc Quality Improvement Performance Committee meeting to review progress on the plan; recommendations approved
Improper Use of Power Strips and Extension Cords in Multiple Facility Areas
Penalty
Summary
Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.
Plan Of Correction
The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.
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